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Gender identity affirmation: What GPs need to know

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Besides close family, the GP was the first person Linda* told about wanting to change her gender.
 
‘I went to my local GP who I had been seeing off and on for some time,’ Linda said.
 
‘I broached the subject with her and said, “Look, I have got this situation, I don’t feel right”.’
 
For Linda, who was born a male, the decision to approach the GP in her 50s was a big ‘milestone’, and she didn’t know what to expect.
 
Luckily, it turned out well.
 
‘I got a very positive reaction because she didn’t throw her hand in the air and tell me she didn’t know what to do,’ Linda said.
 
‘Because I have got friends who have said that about their GPs. I was quite lucky, she was very respectful.
 
‘She said, “I don’t really have a lot of experience in this area, but we can find somebody”.’
 
The RACGP’s curriculum includes a chapter on sex, sexuality, gender diversity and health, but lesbian and bisexual women’s health GP and University of Melbourne Associate Professor Ruth McNair said training organisations often approach it in an ad hoc and cursory manner.

Lesbian and bisexual women’s health GP and University of Melbourne Associate Professor Ruth McNair says gender identity is a growing area.​
 
‘It is a growing need,’ Associate Professor McNair said.
 
‘I think transgender identity issues needs a specific area of training. It needs to be taught … at medical school level, and then also progressing into GP training and then available as professional development activities for trained GPs.’
 
Although, she said, there is no reliable available data, estimates show that at least 2–3% of the Australian population is transgender or gender diverse.
 
‘It is much higher than we ever expected in the past,’ Associate Professor McNair said.
 
‘If you look at the Royal Children’s Hospital and Monash Health Gender Clinic, statistics show an exponential rise in the referrals to each of those clinics in the last five years.’
 
Her own patients have ranged from people who had just started exploring their gender and wanted some support, to those who had affirmed their gender some years before but couldn’t find appropriate primary care because of discrimination.
 
Associate Professor McNair said she has heard many times about patients who have been refused care at general practices.
 
‘I have heard so many times of patients who are either turned away, they are told it is a specialist issue and the GP doesn’t have any knowledge.
 
‘Or worse they are told they are abnormal and that they need curing. They are sent to a psychiatrist to try to convert them back to a cisgender identity.
 
‘It’s a bit like people who were lesbian or gay 30, 40 years ago who were pathologised. Transgender people now are getting that experience unfortunately from many doctors. ’
 
Associate Professor McNair said this attitude forces many transgender and gender diverse people to miss out on primary care.
 
‘A Curtin University study of the mental health of over 900 transgender and gender diverse people showed very high rates of depression, anxiety and suicidal thoughts,’ she said.
 
‘They asked suicidality in the previous two weeks prior to the survey, and it was around 25%.’
 
Associate Professor McNair, who will launch an online training module for GPs later this month, recommends the following for GPs if approached by a patient who is experiencing gender identity issues:

• For anyone, at any age, seeking medical treatment for their transition [gender affirmation], refer them to a psychologist or a psychiatrist for a gender assessment. This is to ensure that they are well enough to go through affirmation and that there is no other psychiatrist illness that may be interfering with their identity.  
• Affirm the patient’s gender in the clinic. Use the right name and right pronoun, including in the medical records.  
• Either refer to an endocrinologist or initiate hormones for transition or affirmation care. GPs can also help with the maintenance including prescribing and monitoring hormones.  
• The patient may need to be referred to a speech pathologist.  
• Offer support with any family fallouts.  
• Referral to surgery as needed.

Associate Professor McNair said GP should treat transgender or gender diverse people as they would any other patient and offer lifelong support.
 
However, she said, being a transgender or gender diverse person is not a disease.
 
‘Some people have gender identity that doesn’t match their birth-assigned gender, that’s a normal fact, it’s a variation of gender,’ she said.
 
‘But many of them need medical treatment to affirm that gender, otherwise they can’t live the life that they need to. It’s not a disease, but we have to provide diagnostic categories in order to provide medical treatment.’
 
Sexual health physician Dr Vincent Cornelisse said providing medical care for someone who is gender diverse requires a multi-faceted holistic care, which makes GPs ideally placed to help.

Sexual health physician Dr Vincent Cornelisse says clinic registration forms should ask new patients their gender in a way that allows gender diverse people to list their gender.​
 
‘The needs of trans and gender diverse people are broad and varied, and include mental health care,
social support, and management of hormone treatment and surgery.’ Dr Cornelisse said.
 
‘GPs already have the skills needed to support gender diverse people, essentially it is no different to providing holistic care for other patient populations, and to do it well requires some understanding of the language and cultural contexts that are unique to trans and gender diverse people.’
 
He said health practitioners have to be careful not to make assumptions and learn about the different gender identities that people can have.
 
For example, the person sitting in front of you might identify as a trans man or a trans woman or they might identify as a man, not a trans man, but they may have been assigned a female sex at birth,’ Dr Cornelisse said.
 
‘And it is important to get that right, to understand what that person’s gender identity is so you can talk to them in a way that respects their gender identity.’
 
He said the easiest way to understand what someone’s gender identity is to respectfully ask the person what their gender is, and what pronouns they prefer to use.
 
‘Ideally, clinic registration forms would ask new patients their gender in a way that allows gender diverse people to list their gender,’ Dr Cornelisse said.
 
‘International best practice around gender data collection consists of a two-stage gender question, firstly asking what sex the person was assigned at birth and then asking what their gender is.’
 
Dr Cornelisse said Australian GPs had a very broad clinical practice and they were very competent.
 
‘I don’t think patients expect all GPs to necessarily be experts in transgender healthcare,’ he said.
 
‘In the end it comes down to being respectful, being empathetic and recognising the limitations of your skills and knowledge, being willing to upskill when you see new clinical scenarios, and knowing where to refer when you need some back-up.’
 
*Not her real name

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gender diversity sexual health transgender

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